Purpose: Evidence concerning the effect
of circumcision on sexual function is lacking. Men circumcised as adults are potentially in a
unique position to comment on the effect of a prepuce on
sexual intercourse. We examine sexual function
outcomes in men who have experienced sexual intercourse in
the uncircumcised and circumcised states.

Materials and Methods: Men 18 years old
or older when circumcised were identified by billing records
during a 5-year period at an academic medical center. Medical
charts were reviewed for confirmation of the procedure and to
identify the indication(s). These men were surveyed to assess
erectile function, penile sensitivity, sexual activity and
overall satisfaction. Data were analyzed using paired t tests
to compare category scores before and after circumcision.

Results: A total of 123 men were
circumcised as adults. Indications for circumcision included
phimosis in 64% of cases, balanitis in 17%, condyloma in 10%,
redundant foreskin in 9% and elective in 7%. The response
rate was 44% among potential responders. Mean age of
responders was 42 years at circumcision and 46 years at
survey. Adult circumcision appears to
result in worsened erectile function (p = 0.01), decreased
penile sensitivity (p = 0.08), no change in sexual
activity (p = 0.22) and improved satisfaction (p = 0.04). Of
the men 50% reported benefits and 38% reported harm. Overall,
62% of men were satisfied with having been circumcised.

Conclusions: Our findings may help
urologists better counsel men undergoing circumcision as
adults. Prospective studies are needed to better understand
the relationship between circumcision and sexual
function.

KEY WORDS: circumcision, adult, sex

[CIRP note: Most (84%) of the men in
this study had a preexisting problem of phimosis, balanitis,
or condyloma. There was no clear sample of normal, healthy,
intact men for comparison. Even so, thirty-eight percent of
the circumcised men were dissatisfied with the results of
their circumcision.]

Scientific information that physicians can
use as a basis for recommending or not recommending
circumcision in neonates or adults is limited. Controversy
surrounding neonatal circumcision continues to exist. Neither
the American Academy of Pediatrics, American Academy of
Family Physicians nor American Urological Association has a
specific recommendation endorsing or opposing
circumcision.1-3 However, these
organizations do have policy statements on circumcision
recommending the unbiased discussion of the evidence
regarding this procedure. The evidence concerning the effect
of circumcision on sexual function is lacking.

Beliefs differ on how circumcision affects
the sensitivity of the glans and pleasure with sexual
intercourse. Some believe that circumcision results in
diminished sensitivity of the glans,1,
4 whereas others believe that it results in more
pleasurable sexual intercourse.5-7 A study by Pienkos, a military
surgeon who surveyed men requesting circumcision during the
Korean War, revealed that men requested circumcision with the
expectation of improved sexual satisfaction.8 The sensitivity of the glans and
pleasure with sexual intercourse as dependent on the presence
of foreskin have received little formal investigation.
Masters and Johnson performed neurological testing on the
glans of circumcised and uncircumcised men finding no
significant difference in sensation.5 To our knowledge no study in this
regard has been conducted on men undergoing circumcisions as
adults.

Men who have undergone
circumcision as adults are potentially in a unique position
to comment on the effect of a prepuce on sexual
intercourse. We examine erectile function, penile
sensitivity, sexual activity and overall satisfaction in men
who have experienced sexual intercourse in the uncircumcised
and circumcised states.

METHODS

Participants. We identified men who
were circumcised at age 18 years or older by reviewing
billing records at the University of North Carolina at Chapel
Hill Medical Center between January 1, 1995 and December 31,
1999 for Current Procedural Terminology code 54161. Medical
charts were reviewed to confirm that the procedure had been
done and to determine the indications. We then developed a
survey in-strument to gather additional information. The
institutional review board at the University of North
Carolina at Chapel Hill approved this study.

Survey instrument. We investigated the
effect of circumcision on erectile function, penile
sensitivity, sexual activity and overall satisfaction.
Existing indexes, scales and questionnaires were reviewed for
ability to evaluate these categories. Although certain
individual questions were applicable, no instrument had been
specifically designed to evaluate these sexual function
outcomes. Items from the International Index of Erectile
Function, Changes in Sexual Functioning Questionnaire, Brief
Sexual Function Questionnaire, Center for Marital and Sexual
Health Functioning Questionnaire, and National Health and
Social Life Survey were included or adapted.9-13

The survey contained questions to obtain
demographic information (age, race), co-morbidities
(depression, diabetes, heart disease) and basic sexual
histories (sexual orientation, sexual activity before and
after circumcision). To evaluate sexual function outcomes we
used Likert scales ranging from 1 to 5 to measure strength of
agreement/disagreement with statements and to quantify the
frequency of specific sexual practices. We asked responses
for before and after circumcision. We also included open
ended questions to gather descriptive information about
perceived benefits and harms, and any general comments.

Discussions were held with men who had
undergone adult circumcision to identify issues important to
them. Their input helped us decide what types of questions to
include in the survey. Once designed, the survey was
pretested and modifications were made. The anonymous surveys
were coded to allow tracking. Addresses were obtained from
billing information. After the first mailing 3 successive
mailings were sent to nonresponders.

Statistical analysis. We compared
responders to nonresponders by age at circumcision and age at
survey using paired t tests. We used chi-square goodness of
fit analysis to compare indication and Pearson's chi-square
test for race. We then limited further analysis to
heterosexual men to enhance internal validity of the study.
We analyzed all heterosexual responders together to find the
overall effect of circumcision on all men, and we also
analyzed the subgroup of men who had sex with the same
partner before and after circumcision to control for
different sexual experiences with different partners.

For individual items on the survey we
performed paired t tests on the Likert scores before and
after circumcision. The Likert scores for 3 items were
combined to yield each of the 4 category scores of sexual
function outcomes, such that all categories had a potential
maximum score of 15. The survey items used to calculate each
category score are shown in the Appendix. Sample size was not
sufficiently large to perform factor analyses. Items were
grouped into a priori categories based on similarity of
content. Higher scores for all of the categories represent
increases, and so for some items the Likert scale scoring was
reversed. Therefore, all responders had 4 category scores for
sexual function before and 4 scores for after circumcision.
We used paired t tests to compare each category score before
and after circumcision.

We adjusted for age by performing linear
regression in which the outcome was the category score after
circumcision, the main exposure was the category score before
circumcision, and the potential covariable was the difference
between the age at survey and age at circumcision. The age at
survey differed from the age at circumcision by the time
elapsed since the procedure. Since men served as their own
controls, we were able to adjust for age by using change in
age. We compared the prevalence of co-morbidities before and
after circumcision using McNemar's chi-square test, and since
they did not differ significantly, we did not otherwise
adjust for them. All statistical analyses were performed
using Stata 6.0 (Stata Corporation 1999, College Station,
Texas).

RESULTS

From billing records 133 patients were
identified as having had adult circumcisions and 123 of these
procedures were confirmed on chart review. The indications
for the procedures are shown in table 1. Phimosis was the
most common indication, 9 men (7%) underwent an elective
procedure and 1 man was circumcised for penile cancer. Of the
123 surveys initially mailed 5 were returned by family
members indicating that the patient was dead. Another 20
surveys were returned by the postal service because the
address was incorrect and no forwarding information existed.
A total of 43 completed surveys were returned for a response
rate of 44% for potential responders and a rate of 35% for
all patients having undergone adult circumcision.

The responders were representative of
nonresponders by age at circumcision, age at survey and
indication, but not by race (table 2). No Hispanic men
responded. Of the responders 40 (93%) identified themselves
as heterosexual and no men reported that they were bisexual.
Of all responders 90% had had sex before the procedure, 86%
had sex after the procedure, and 79% had sex before and after
the circumcision, including 72% had sex before and after with
the same partner. Those who had sex after circumcision waited
an average of 9 weeks.

Compared to before circumcision, men reported
reduced erectile function, decreased penile sensitivity, no
change in sexual activity and improved satisfaction after
circumcision (table 3). We found essentially the same trends,
although the magnitude differed, among the subgroup of men
who had sex with the same partner before and after
circumcision except that these men experienced increased
sexual activity.

The reduction in
erectile function was statistically significant. Some men
were unable to have erection after the procedure but even
those who were able to have sex with the same partner before
and after the procedure reported worsened erectile function.
This difference remained significant when adjusted for age
and co-morbidities. Some comments were: "Erections are
shorter time now." "Penis smaller. Now have erectile
dysfunction."

The reported decrease in
penile sensitivity that resulted from circumcision bordered
on statistical significance. Men who had sex with the same
partner before and after circumcision reported greater
reduction in penile sensitivity than other men. How
men viewed the decreased penile sensitivity differed:
"Somewhat less sensitivity helps prolong intercourse." " I
had been warned that I would lose sensitivity, but overall, I
feel that I was not completely informed."

The all responders group reported worsened
erectile function and decreased penile sensation, as well as
decrease in sexual activity that was not statistically
significant. However, men in the same partner group actually
reported increased sexual activity but this too was not
statistically significant. The comments were mixed: "No sex
drive." "Sex is a lot better."

A higher satisfaction score represented a
more pleasing appearance of the penis and less pain. After
circumcision there was a statistically significant
improvement in how men thought the penis looked to them and
to their partners, and a reduction in pain experienced with
erection. "It don't hurt to have intercourse or get an
erection." "More pleasing to look at." "I feel like I have a
penis that I'm proud of now." After circumcision men were
more likely to have their partners start sexual activity with
them, more likely to receive oral sex, and as likely to
perform anal sex, try different sexual positions and
masturbate, but none of these changes was statistically
significant. The subgroup of men who had sex with the same
partner before and after circumcision were more likely to
have their partners start sexual activity with them (p =
0.05), more likely to receive oral sex (p = 0.08) as likely
to perform anal sex and masturbate, and more likely to try
different sexual positions (p = 0.33).

Of the responders 47% reported that sex was
physically more pleasurable and 47% also said that their sex
lives were more satisfying after circumcision. Additional
comments included improved penis cleanliness and easier
voiding after circumcision. When asked generally about
benefits and harms, 50% reported a perceived benefit or
improvement, and 38% reported a perceived problem or
difficulty as a result of the procedure. Overall, 62% of men
were satisfied with having been circumcised.

DISCUSSION

Although many have speculated about the
effect of a foreskin on sexual function, the current state of
knowledge is based on anecdote rather than scientific
evidence. Myths have mostly addressed changes in penile
sensitivity but some have also regarded sexual activity and
satisfaction with appearance. Little has been written about
the effect of circumcision on erectile function. Few studies
have investigated the relationship between male circumcision
and sexual function.14

Pleasure with sexual activity could mean
enjoyment of the shared sexual act and being a good sexual
partner, or it could reflect a pleasing sensation from
physical stimulation. Many believe that circumcision reduces
penile sensitivity1, 4 but some
believe that it prolongs intercourse 7 and provides greater pleasure during
sexual intercourse.5-7 Theories
to explain the decreased sensitivity are that the epithelium
of a circumcised glans becomes cornified 3 and sensory nerve receptors in the
glans become desensitized from constant stimulation.15 Taylor et al offer a histologically
based theory on how the prepuce enhances sensitivity through
it's "ridged band."16Masters and Johnson performed
exteroceptive and light tactile discrimination on the ventral
and dorsal surfaces of the penis, with particular attention
to the glans, of circumcised and uncircumcised men finding no
clinically significant difference.5 We found a statistically significant
decrease in penile sensation following circumcision in men
but our respondents had mixed feelings. Some responders
appeared to be better able to satisfy their partners after
circumcision but some men were not satisfied with the
decreased sensation of physical stimulation. It seems that
sexual pleasure means different things to different men and
should be more specifically defined in future studies.

Although 1 myth concerning the appearance of
the penis is that the uncovered glans is more aesthetically
pleasing,17 some parents decide
to have the newborns circumcised because they believe it will
make him look better.18 In a
survey of college women 87% expressed preference for pictures
of circumcised over uncircumcised penises.19 We found that the men in our study
and their partners were more likely to think that the penis
looked good after circumcision.

Laumann et al analyzed data from the National
Health and Social Life Survey and found that circumcised men
were slightly less likely to experience sexual dysfunction
and were somewhat more likely to engage in more elaborate
sexual practices, such as oral sex, anal sex and masturbation
than uncircumcised men.20We found that circumcised men were instead
more likely to have erectile dysfunction. Our study
populations differ in that we evaluated men circumcised as
adults but the worsened erectile function remained when
adjusted for age and the presence of diabetes, depression and
cardiovascular disease. A few men reported concern that the
penis was smaller after circumcision. Perhaps circumcision in
some men is psychologically traumatic and interferes with
erectile function. Like Laumann et al, we found increased
frequency of oral sex in men after circumcision but we found
no change in the frequency of anal sex or
masturbation.

Because this study was cross-sectional rather
than prospective, it is limited by recall bias. However, the
directionality of that bias is unclear. Since we did not
assess men's expectations before they were circumcised, we
are unable to comment on how their expectations might have
affected their biases. Another limitation is that men may
have been recalling sexual experiences before circumcision
when suffering from the medical problem that was the
indication for the procedure. However, if circumcision was
supposed to correct the problem then we would have expected
entirely favorable outcomes. Instead we found worsened
erectile function and decreased penile sensitivity.

Our small sample size reduces the power of
the study and, therefore, the ability to detect small but
significant changes and, although responders to the survey
appear similar to nonresponders, generalizeability may be
limited. Our analysis of only responders and of men who
underwent circumcision rather than alternative treatments
creates potential for selection bias. This study is patient
oriented and analyzes subjective reports. Objective data,
such as duplex Doppler ultrasound and penile biothesiometry,
are needed to assess erectile function and penile sensation
before definitive conclusions can be made. Since we studied
circumcision in adults, our findings may not be
generalizeable to neonatal circumcision. Our survey
instrument was not formally tested for reliability or
validity.

CONCLUSIONS

To our knowledge we present the first study
to evaluate specifically men who experienced sexual
intercourse in the uncircumcised and circumcised states.
Although our study has some methodological limitations, it
contributes to our knowledge about the effect and outcomes of
adult circumcision. We found that adult
circumcision appears to result in worsened erectile function,
decreased penile sensitivity and improved satisfaction.
Overall, the majority of men were satisfied that they had
undergone circumcision which suggests that in this population
factors in addition to sexual function affect
satisfaction. Our findings may help urologists better
counsel men about adult circumcision. Prospective studies,
including those with objective measurements, are needed to
better understand the relationship between circumcision and
sexual function.

David Collins provided administrative
assistance with this project.

APPENDIX: ITEMS INCLUDED IN THE SEXUAL
FUNCTION
OUTCOMES CATEGORIES

Erectile Function
I am able to get an erection.
My erection is firm enough for penetration.
I am able to maintain an erection during sex.
Penile Sensitivity
It takes me longer than I like to have an orgasm.*
My penis is not sensitive enough.*
I have premature ejaculations.
Sexual Activity
I think about having sex.
I start sexual activity with my partner.
I have vaginal sex.
Satisfaction
I have pain in my penis with erection.*
I think my penis looks good to me.
I think my penis looks good to my partner.* Likert scale scoring was
reversed.